Modern Board Accelerator Form Please answer the following questions. Question Title * 1. Please provide the following information. Organization Name Organization Address Organization City/Town Organization State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Organization ZIP/Postal Code Organization Website Question Title * 2. Industry: What industry is the organization in? Supplier/Vendor Pharmaceutical Association Research organization/think tanks Government Agencies Hospital/Health System (If you select this answer, please specify whether the organization is For Profit, Not-for-Profit, or an Academic Institution) Question Title * 3. Market: Who does the organization serve? (Customers and stakeholders) Question Title * 4. Progress: Where is the organization in its board search process? Just starting Half-way Almost finished Question Title * 5. Timing: When does the organization hope to complete the board search process? Question Title * 6. Strategy: What other strategies or resources are you using to find new board members? Please specify. Question Title * 7. Contacts: Please provide the following contact information about yourself. Your Name Your Title Your Email Address Your Phone Number Question Title * 8. Referral Source: How did you hear about the Modern Board Accelerator program? Question Title * 9. Do you have any requirements or preferences? Please select all that apply. Track record of executive leadership Board, committee or task force experience Knowledge of healthcare providers, payers, suppliers and/or consumers Knowledge of the organization Superior emotional intelligence and communication skills Knowledge, skill or experience in Digital transformation Knowledge, skill or experience in Consumer engagement Knowledge, skill or experience in Marketing and promotion Knowledge, skill or experience in Clinical innovation Knowledge, skill or experience in Business partnerships Knowledge, skill or experience in Diversity, inclusion and equity Knowledge, skill or experience in Finance Knowledge, skill or experience in Retail Other (please specify) We’ll contact you within three business days to set up a call or virtual meeting where we can learn more about your board needs and priorities, and specific search criteria. Done
